Get bumpers out of cribs, doctor group urges

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The AAP now recommends that infants sleep on their backs on a firm mattress, without any soft objects or loose bedding.

Story highlights

No evidence bumpers protect against injuries, American Academy of Pediatrics says

Recent studies have shown bumpers may be more hazardous than thought

National Center for Child Death Review has received 14 reports of infant suffocation

Bumper pads should never be used in infants' cribs, according to new guidelines released by the American Academy of Pediatrics.

This recommendation, issued as part of an updated and expanded set of guidelines on safe sleep and SIDS prevention for babies, is the first time the AAP has officially come out against the use of crib bumpers. According to the AAP, there is no evidence that crib bumpers protect against injury, but they do carry a potential risk of suffocation, strangulation, or entrapment because infants lack the motor skills or strength to turn their heads should they roll into something that obstructs their breathing.

When the AAP issued its last policy statement on sudden infant death syndrome in 2005, it recommended using bumpers that were thin, firm, well secured, and not "pillowlike."

What's behind the change in thinking to remove bumpers altogether? Recent studies have shown that bumper pads may be far more hazardous than previously thought. "In 2005, when we last published a policy statement and recommendations, we had some concerns about bumper pads, but we didn't really have a lot of evidence that this was a real problem," said Rachel Moon, M.D., FAAP, of the Children's National Medical Center in Washington, D.C, chairperson of the AAP SIDS task force and lead author of the new guidelines. "Since then, there have been some published studies looking at bumper pads, and we concluded that if there's no reason for them to be in the crib, it's better to just have them out of there, particularly in light of the deaths that have been reported, that have been associated with the bumper pads."

Since the AAP released its landmark guidelines in 1992 that all babies be placed on their backs to sleep, deaths from SIDS dramatically decreased initially, but have plateaued in recent years. At the same time, sleep-related deaths from other causes, including suffocation, entrapment and asphyxia, have increased.

Anti-Bumper Sentiment Growing

One of the major turning points in the medical community's attitude toward bumpers was a study published in the September 2007 issue of The Journal of Pediatrics that examined deaths and injuries attributed to infant crib bumper pads, based on information from the Consumer Product Safety Commission for 1985 through 2005. Researchers found reports from medical examiners and coroners of 27 accidental deaths of children ages 1 month to 2 years, that were attributed to suffocation when they became wedged against a padded bumper or strangulation by a bumper tie around the neck. Eleven of the infants who died most likely suffocated when their face rested against the bumper pad, 13 infants died when they became wedged between the bumper pad and another object, like the crib mattress, and three infants died when they were strangled by a bumper tie. The conclusion of that study read, "These findings suggest that crib and bassinet bumpers are dangerous. Their use prevents only minor injuries. Because bumpers can cause death, we conclude that they should not be used."

The CPSC initially interpreted this data differently and in the summer of 2010, reached the same conclusion as the Juvenile Products Manufacturers Association, which had conducted its own analysis of an unpublished CPSC review of crib deaths involving suffocation or strangulation. The JPMA asserted that other factors, like babies sleeping on their stomachs or a crib filled with pillows, might have been a factor in those deaths instead of the bumpers. Less than a year later, the CPSC announced it would take a closer look at crib bumpers in response to consumer advocates and news reports, especially those from the Chicago Tribune, highlighting potential dangers, as part of a broader regulatory crackdown on an array of baby sleep products blamed for injuries and deaths. As part of that crackdown, in September 2010, the CPSC along with the Food and Drug Administration warned parents of the dangers of infant sleep positioners, some of which had been marketed to reduce the risk of SIDS but in fact had caused up to a dozen suffocation deaths of babies in about as many years.

Why is action being taken now to protect infants from the potential dangers of crib bumpers? Reports in the Chicago Tribune from late 2010 and early 2011 alleged that federal regulators had known for years that crib bumpers posed a suffocation hazard but had failed to warn parents of the danger and took the CPSC to task for failing to investigate 17 of the 52 reports it had received over a 20-year span of infant deaths where bumper pads were mentioned but not necessarily ruled as the cause of death. Twenty-eight of those deaths had already been associated with bumper pads by the agency. The Tribune also found that since 2008 the federally funded National Center for Child Death Review has received 14 reports of infant suffocation in which a bumper was relevant in the death.

While the coverage in the Tribune pushed the CPSC to take a closer look at the safety of crib bumpers, local governments also started to act. On September 8, 2011, Chicago became the first city in the U.S. to ban the sale of crib bumpers. Less than three weeks later, on September 28, 2011, Maryland became the first state to propose a ban on sales of crib bumpers.

Why Many Parents Are Still Using Bumpers

Why are bumpers still so popular despite building evidence that they aren't safe? For starters, many parents believe bumpers prevent injury from a baby's head hitting the sides of a crib, or from limbs getting stuck in the slats. And indeed, bumpers were first conceived to cover the space between crib slats so babies couldn't fall out or get their heads, arms or legs stuck between the bars. But regulations changed in the 1970s and now mandate less space (just 2 3/8 inches—about the width of a soda can) between slats, making bumpers more an aesthetic choice than a safety necessity.

As to the question of safety, Moon explains that young babies (for whom bumpers are designed, given that many carry a warning suggesting that they be removed from the crib once a baby can pull himself to standing) don't have the muscle strength or coordination to fling themselves across the crib hard enough to really injure themselves. Additionally, she adds, while it is possible for a baby to get an arm or a leg stuck between crib slats, it's virtually impossible to break a limb by doing so—which means that at most, the experience will be uncomfortable and upsetting, but not life-threatening, until a caregiver arrives to help.

Parents also buy bumpers because they think they're supposed to, given that they're sold in crib bedding sets, and because they just plain look good, explains Moon. And there's little question that modern nurseries tend to look cozier or more "finished" with bumpers, but Moon added that if parents stop buying bumpers and manufacturers stop making them, perhaps attention will ultimately be focused on other ways of making a nursery look cute.

Although the general counsel for the JPMA warned that should sales of bumpers be banned, parents might start to jerry-rig their own bumpers, Moon said, "There's always concern that parents are going to create things and make things when they see the need to do that. Our responsibility is to let parents know that some of these products are not safe, and we need to understand that this may be an issue and proactively talk to parents about these concerns so that perhaps they'll be less likely to do things like that. My hope is that parents learn about these things in prenatal classes, through their obstetrician's offices, through other places like that before the baby is born and before they've actually gone out and purchased these products."

Bumper Alternatives: Are They Safe?

As an alternative to traditional crib bumpers, some parents have turned to breathable, mesh bumpers or other bumper alternatives, but Moon said that the AAP does not suggest that parents buy them. "We're, right now, recommending nothing in the crib, because again, we don't see the point of it. So, why have something in the crib if it's not there for a reason?"

Will Retailers Follow Suit?

The AAP now recommends that infants sleep on their backs, alone in a crib on a firm mattress, without any soft objects or loose bedding, which could also be hazardous, ideally in a room shared with a parent. Really, all that's necessary when it comes to baby bedding is a fitted sheet.

Despite the fact that the AAP warned that crib bumpers could pose a serious safety risk to infants as early as 2008, little has changed when it comes to what expectant parents can find in their local baby super store—in part because baby bedding is big business. The JPMA says that at least $50 million worth of infant bedding sets that include bumpers are sold each year, as well as more than 200,000 bumper pad sets.

Unfortunately for parents, it can be confusing to see bumpers on display in stores, not to mention challenging to find crib bedding sold without bumpers, since bedding is often sold in four-piece sets, including a sheet, crib skirt, bumper, and quilt (which doesn't belong in a safe sleep environment for an infant anyway). But it's not impossible; Carousel Designs, for example, offers a la carte options for purchasing coordinating fitted crib sheets and crib skirts, and retailers like Babies"R"Us and Buy Buy Baby, as well as web sites like Amazon.com, offer standalone fitted crib sheets.

Moon said that she hopes retailers will stop selling crib bumpers in response to the AAP's updated guidelines. "The problem is that a lot of parents don't understand that the Consumer Products Safety Commission is not a proactive agency; it's a reactive agency. So, it only recalls things if there's a problem. It doesn't approve products before they go on the market. And a lot of parents have this perception that it stores sell it, it must be safe—because if it wasn't safe, why would people sell it? And that's clearly not true. I think that it's important that parents realize that these things are not safe for their babies."

Additional Safe Sleep Advice: Breastfeeding & Vaccination

The AAP has also made a couple of other important additions to its safe sleep recommendations. Breastfeeding is now recommended specifically as a method of reducing risk of SIDS. Dr. Moon explains that as of the most recent policy statement in 2005, the AAP didn't have enough evidence to associate breastfeeding with a reduced risk of SIDS, although the connection had been established between breastfeeding and a lower risk of infant mortality overall, but since then, "there have been several studies that have come out that have demonstrated pretty unequivocally that breastfeeding is protective. So, we wanted SIDS risk reduction to be on the list of the many reasons why we should breastfeed." As of now, medical professionals still don't understand exactly how breastfeeding helps to lower risk of SIDS, and Moon explains that it may have to do with "anti-inflammatory properties of breastfeeding, or it may have to do with the fact that breastfeeding decreases infections in babies, because we know that babies who die of SIDS are more likely to have had a recent infection. It could be a whole host of things, and there are researchers that are looking at that." While the AAP recommends, when possible, that mothers exclusively breastfeed for 6 months, any breastfeeding has been shown to be more protective against SIDS than no breastfeeding.

And finally, the AAP now recommends infant immunization as a SIDS risk reduction strategy as well, as there is evidence that immunization reduces the risk of SIDS by 50 percent. This recommendation is particularly notable because, Moon explains, there has been a lot of concern amongst parents that vaccinations may cause SIDS: "I think it's largely because the high risk period of SIDS is between 2 and 4 months, and that's when babies start getting a lot of immunizations." She points out that the rate of SIDS has decreased while the number of immunizations infants receive in that period has gone up in the last 20 years, and that recent studies have shown that there is no cause-and-effect between SIDS and immunizations—and that babies who are fully immunized are at half the risk of dying of SIDS than babies who are not fully immunized, although the why's behind these relationships are not fully understood as of yet.